Solving the HIV/AIDS Drug Access Crisis In Africa: Meeting the Challenge to Save Millions of Lives and to Mitigate the Orphan Crisis

A Congressional Briefing delivered in Washington, D.C. by Rachel Cohen, Advocacy Liaison for MSF's Access to Essential Medicines Campaign

Thank you for the opportunity to participate in this briefing.

As many of you may know, Doctors Without Borders/Médecins Sans Frontières (MSF) is an international independent medical humanitarian organization. We run some 400 medical aid projects in over 85 countries. I hope to offer today the perspective of MSF field volunteers working to fight AIDS and other communicable diseases in poor countries throughout the world.

The global AIDS crisis is finally making headlines in the United States. Public outcry over alarming death rates from the disease has at last begun to catalyze political action. For MSF, the recent attention paid to the AIDS pandemic and, to a lesser degree, other major communicable diseases such as malaria and tuberculosis, is welcome. But for us, the startling statistics—36 million people infected with HIV, 2 million deaths per year from TB, 300-500 million new cases of malaria each year—are not just numbers on a fact sheet or report. They are our patients, and we are watching them die every day because the medicines they need are either too expensive or simply do not exist.

Several weeks ago, a colleague from Nairobi, Kenya, Dr. Chris Ouma, visited the US as part of MSF's delegation to the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS. He recounted one evening a chilling but all too common story about one of his patients, Simon. Simon had traveled to Nairobi from a neighboring village to see Dr. Ouma, and complained during the examination of severe headaches. No matter how many aspirins he took, the pain would not subside. Dr. Ouma ran a few tests and within minutes had confirmed the diagnosis he feared: cryptococcal meningitis, an HIV-related fungal infection that affects about one in every 10 people with AIDS and, if left untreated, is fatal, often within weeks. When Dr. Ouma returned to the examining room, he had to deliver not one, but two devastating blows: First, he had to tell Simon that he was HIV-positive. Second, he had to explain that, although an effective treatment existed, he could not prescribe it, because at $10 per pill, Simon would use his entire salary in just two weeks (and treatment with fluconazole, the effective drug, is for life). Although the same drug is available generically in Thailand for 10 cents a pill, Dr. Ouma had to explain to Simon, his wife, and their two children, that they should return home at once: Transporting a living body from Nairobi would be significantly less expensive than transporting a corpse. This is just one story among hundreds that MSF doctors in the field face on a daily basis.

MSF's field experience with the HIV/AIDS crisis began in the late 1980s. Initially, the organization devoted its resources to preventing the spread of the disease. By 1997, MSF was running 30 HIV/AIDS projects, still aimed primarily at prevention. However, by this time, powerful but expensive new drug "cocktails" of antiretroviral therapies were dramatically extending and improving the lives of people with AIDS in wealthy countries.

Meanwhile, infection rates soared in the developing world. It was clear that "prevention only" measures were not stemming the spread of the disease. In addition, for MSF doctors, it was unethical and unacceptable to send their patients home to die simply because the new medicines were unaffordable. With this in mind, the question was no longer whether to begin HIV/AIDS treatment in poor countries, but how.

Although somewhat limited, MSF's field experience with HIV/AIDS shows what many already knew to be true: that offering treatment is indeed feasible, even in resource-limited settings. Although quantitative data from our projects are limited, my colleagues working in MSF's pilot antiretroviral treatment programs—there are currently nine such programs in seven countries—have found that offering the possibility of treatment is a powerful incentive for individuals to get tested and learn their HIV status, a crucial first step for effective prevention activities. In addition, they have found that the hope of treatment helps break the vicious cycle of denial of the disease and of social stigma associated with HIV. Offering treatment also motivates poor communities to mobilize resources and strengthen their health-care infrastructures.

Although more political attention than ever is focused on the AIDS crisis in the developing world, challenges to adequate care and treatment for people living with HIV in resource-limited settings remain daunting. There is still an urgent need for operational research to determine how to best provide and monitor antiretroviral treatment in resource-poor settings. Substantial investment is also needed in health-care delivery systems—personnel, diagnostics, supplies, equipment, and facilities—to sustain care for the long-term: Although the challenge of weak health systems in some areas is formidable, health infrastructure in developing countries is not homogenous, and this challenge can no longer be used as an excuse to deny or delay increased access to life-prolonging medicines. But a reliable supply of antiretrovirals and other medically essential medicines with guaranteed long-term affordability is the first crucial step that must be taken in order to ensure successful treatment (although not the only one).

Price is not the only reason that people with HIV/AIDS are not getting the medicines they need, but it remains a major barrier, and, as was agreed by all member states during UNGASS in New York last month, it must be addressed and overcome at all levels.

As everyone on this panel has mentioned today, increased financial resources from wealthy countries, including the US, is an urgent priority in the fight against AIDS and other diseases. In order to ensure that international funding mechanisms, including the proposed Global AIDS and Health Fund, can offer treatment to the highest number of people with HIV/AIDS, malaria, and TB, it is essential that funds be available for the purchase of medicines and medical technologies at the lowest possible cost. With that aim, MSF recommends the following mutually supportive strategies to ensure equitable and sustainable access to affordable medicines and related technologies:

• Stimulating generic competition, encouraging a differential (or tiered) pricing system, and creating economies of scale through regional or global procurement;
• Encouraging local production through voluntary licensing and technology transfer in countries with domestic drug manufacturing capacity;
• Using TRIPS safeguards (compulsory licensing, parallel imports, and Bolar provisions) through national legislation;
• Encouraging the purchase of medicines from lowest cost suppliers, including generic companies, to maximize the use of the available financial resources (intellectual property barriers need to be overcome by using legal exemptions to patent rights);
• Implementing health exceptions to patent rights for goods purchased with financing from internationally organized global funds;
• Creating a database of information on drug prices, quality, and patent status to help guide decisions of country purchasers.

It is critical that a long-term, sustainable solution to the crisis of lack of access to medicines be developed—not one that relies solely on the good will of pharmaceutical companies to voluntarily offer discounts on certain medicines. Though such price reductions are important, they are extremely vulnerable strategies on their own.

MSF is painfully aware that our organization alone will not be able to provide treatment to all of those in need in the countries where we work. Today, our colleagues working in MSF programs in Malawi or Kenya or South Africa have to choose who will get treatment, and that means they have to choose who will live and who will die. This is an unacceptable position to be in as a physician. But imagine that you are the patient and you know that you will die not because effective treatments do not exist, but because the world has decided that it is too complex, not feasible, or not "cost-effective" to provide you with life-prolonging treatment.

I'd like to close with a quotation from an MSF doctor working in Cameroon, Dr. Laura Ciaffi:

"...Are the drugs everything? Of course not. Are AIDS patients still dying? Of course—by the thousands. But the availability of drugs is having an impact far beyond the relatively few people who are actually receiving them. We have to continue to insist on the principle that medical treatment for AIDS should be provided, even when we cannot do it for everyone and we cannot do it for everyone tomorrow. The principle makes all the difference. Five years ago, when I was an AIDS doctor in Italy, the first really effective antiretroviral combinations were becoming available in Europe. I recently went back to visit my old clinic in Milan, and I was so happy—but surprised—to meet many of my old patients. They were supposed to have died of AIDS years ago. One day, perhaps five years from now, I hope to come back to Cameroon to see the same thing."

Thank you.